Healthcare Provider Details

I. General information

NPI: 1902221484
Provider Name (Legal Business Name): SUSAN KLEIN KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 GAMMON LN
MADISON WI
53719-2210
US

IV. Provider business mailing address

1015 GAMMON LN
MADISON WI
53719-2210
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-8144
  • Fax: 608-271-3457
Mailing address:
  • Phone: 608-417-8144
  • Fax: 608-271-3457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number413-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1195-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: